Abstract

Disparities and inequities in mental health and mental health care have been a persistent and unremitting issue despite concerted efforts on multiple fronts to address the problem. The enduring nature of these differences compels us to evaluate factors that led to our present state, new evidence, and novel strategies to reduce and eliminate mental health disparities and inequities. Discrimination, implicit bias, and the social determinants of mental health all serve to perpetuate mental health inequities. Providers may need to expand their roles as advocates for social change, champions for inclusion, and adjuncts to policymakers in order to reduce (and ultimately eliminate) mental health inequities in the future. [Psychiatr Ann. 2018;48(3):138–142.]

Abstract

Disparities and inequities in mental health and mental health care have been a persistent and unremitting issue despite concerted efforts on multiple fronts to address the problem. The enduring nature of these differences compels us to evaluate factors that led to our present state, new evidence, and novel strategies to reduce and eliminate mental health disparities and inequities. Discrimination, implicit bias, and the social determinants of mental health all serve to perpetuate mental health inequities. Providers may need to expand their roles as advocates for social change, champions for inclusion, and adjuncts to policymakers in order to reduce (and ultimately eliminate) mental health inequities in the future. [Psychiatr Ann. 2018;48(3):138–142.]

Despite consistent attention and resources devoted to the subject, disparities in mental health and mental health care have persisted over time. The complexity of this issue requires a deeper consideration of the structural context that has led to these inequities. This article redefines the issue, addresses new trends in research in the field, and offers innovative solutions that providers and policymakers can adopt to reduce mental health disparities and inequities.

Defining Disparities and Inequities

The gold-standard definition of “disparities” comes from the 2003 Institute of Medicine report, which defines disparities in health care as “racial or ethnic differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention.”1 However, the majority of contributors to differences in health status among populations actually occur outside of the health care system, which only accounts for 10% of early mortality in the United States.2 Thus, in defining these differences, one must consider a definition that also encompasses the impact of genetic, community, environmental, and societal influences on health status. The National Institutes of Health defines health disparities as “differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States.”3 It should be noted that there is no value or judgment placed on these differences; they are just differences observed, but not necessarily inspiring or compelling action. In contrast, the World Health Organization (WHO) defines health inequities as “avoidable inequalities in health between groups of people within countries and between countries,” and notes that health inequities are driven by “the way society…organizes its affairs, giving rise to forms of social position and hierarchy, whereby populations are organized according to income, education, occupation, gender, race/ethnicity, and other factors.”4 The WHO places a distinct value judgment on this definition, along with the clear understanding that the inequities that we see in health status are preventable and the result of power and resource differentials between groups. Such hierarchies create systemic policy issues and structures (ie, housing, education, and the criminal justice system) that exclude and disenfranchise certain population groups from the opportunities for optimal health and positive health behaviors. For example, America's persistent phenomenon of racially hyper-segregated areas of concentrated poverty in the core of many cities is related to diminished access to fresh and healthy food sources, which in turn intensifies nutrition-related disparities.5

Although the WHO definitions are universally accepted throughout the world, in the United States, “health disparities” as a definition has often been used in place of the term “health inequities,” even when referring to health differences that are the result of unjust or unfair policies or practices. There may be many contributing factors to why these words have different usage and meaning in the US, but the general culture of disinclination to confront issues of inequality (including racism, sexism, and homophobia) may be a significant contributor to these differences in terminology among societies. For the sake of precision in language, this article discusses health inequities as the WHO defines them, and thus uses “inequities” instead of “disparities” from this point forward.

Progress and Setbacks in Addressing Mental Health Inequities

According to Healthy People 2020's Midcourse Review, some minimal progress is being made in addressing racial/ethnic and gender inequities in mental health, particularly as it relates to alcohol use disorders, suicide rates among youth, and screening for depression.6 Despite these small gains, very little progress has been made in the 15 years since the federal government began tracking and reporting on health care inequities.7 Underserved racial and ethnic minority groups, particularly Latinx (a nonbinary alternative to Latino/a), African Americans, and American Indians, continue to have lower rates of access to quality care, and continue to have greater levels of disability from mental illness compared to white populations.8,9 Families living in poverty have worse mental health care than families that are not living in poverty. Certain population groups have higher rates of specific mental health diagnoses like posttraumatic stress disorder (PTSD), schizophrenia, and anxiety disorders. Such differences in prevalence can be attributed to environmental, rather than genetic, differences.10 For population groups like children in foster care, transgender people, homeless populations, immigrants and refugees, and victims of trafficking, inequities in outcomes are the result of the same intersecting social determinants of mental health that keep these populations marginalized within American society.

Significant focus is placed on genetic factors and biological research to advance treatment of various disease categories and to decrease morbidity associated with behavioral health conditions. Progress is being made, particularly in areas such as coordinated specialty care, integrated health care delivery models, and precision medicine in psychopharmacologic treatments. Given the amount of resources and energy that are devoted to researching pharmacologic and behavioral therapies and outcomes among people with mental illnesses, lack of progress in addressing mental health inequities is particularly troubling. Although an extensive body of research exists that defines, measures, and categorizes differences in mental health outcomes by demographic variables, little data exist on effective methods to reduce or eliminate mental health care inequities. To make progress in this area, it is important to consider new trends and perspectives in tackling mental health inequities.

Current Trends in Examining Mental Health Inequities

Discrimination and Mental Health

There is extensive research that supports the damaging impact of discrimination on health and mental health outcomes.11 Unlike other social determinants of mental health (eg, food insecurity, adverse features of the built environment, and adverse early life experiences), the effects of discrimination on mental health may be more robust than the effects of discrimination on physical health. Despite compelling studies that support this conclusion,12 many psychiatrists are unaware of the strong associations between discrimination and poor mental health outcomes. People who perceive that they have been discriminated against have higher rates of PTSD, major depressive disorder, and generalized anxiety disorder than those that report having experienced lower levels of or no discrimination.11,13 More specifically, studies documenting the association of discrimination with increased odds of PTSD, depression, substance use disorders, and anxiety disorders have been demonstrated among the following population groups (just to name a few): Chinese Americans;14 older African Americans;15 Latinx immigrants16 and Latinx youth;17 American Indians;18 sexual minorities, including transgender youth;19 and religious groups, including Muslim and Jewish people.20

Structural and institutional discrimination, as they effect, for example, interwoven systems of housing, education, employment, health care, criminal justice, and others, also have a significant impact on individual and population-level outcomes. Lack of access to health care, residential segregation, predatory lending practices, and overrepresentation of underrepresented minority populations in the criminal justice system are examples of structural discrimination that augment mental health inequities.21 Furthermore, specific discriminatory policies can directly lead to higher rates of population-level mental illnesses. For example, in 2005, rates of depression, generalized anxiety disorder, alcohol use disorders, and psychiatric comorbidity were higher among lesbian, gay, and bisexual people living in states with discriminatory policies opposing marriage equality.22 More recently, a 2017 study reports that states with laws supportive of same-sex marriage had lower suicide rates among adolescents who are sexual minorities.23

Structural discrimination is well-documented in the history of American medicine. In psychiatric care, Metzl24 explores the changing demographic in schizophrenia diagnoses in the context of the Civil Rights Movement. Academic psychiatrists described the phenomenon of a brief, reactive, “protest psychosis” among black men, characterizing symptoms as “a denial of Caucasian values and hostility thereto” and describing emotions that “appear withdrawn or shallow, a state often interrupted by flashes of aggressive feeling” and delusions that are “clearly paranoid projections of racial antagonism of the Negroes to the Caucasian group.”25 This form of structural discrimination, perpetuated by psychiatrists, removed people from the sociopolitical context of the time and placed the psychopathological symptoms within the person, without proper consideration of the societal forces that were causing psychological distress among this specific demographic group. The result was an incomplete and inaccurate view of suffering that has served to stoke racial/ethnic inequities in schizophrenia diagnoses rates that persist today.

Implicit Bias

Implicit (or unconscious) bias is defined as the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner. The role of clinicians' implicit bias, leading to poor health outcomes, particularly among special population groups, has been extensively examined.26 African Americans are more likely than white Americans to have pain medication withheld.27 Also, they are less likely to receive lifesaving procedures such as thrombolysis for myocardial infarction, in part due to health care providers' assumptions about racial differences in cooperation with medical procedures.28,29 Implicit bias in medical school admissions also contributes to lack of diversity in the physician workforce.30

Despite the substantial data on implicit bias in health care decision-making, research on implicit bias in mental health care is sparse. Few large-scale studies have addressed how implicit bias affects people with mental illness and the treatment they receive. Much of the available data looks at implicit bias as it relates to stigma in mental health. Given the somewhat subjective nature of mental health assessments and diagnoses, the evaluation and treatment of mental illnesses are filtered through the lens of the providers' cultural experiences, values, and beliefs. In a field that uses countertransference as an important tool, implicit biases left unexplored may be detrimental to the therapeutic alliance and patient care. Implicit bias, both within and beyond the confines of the patient-provider relationship, most likely plays a significant role in contributing to mental health inequities.

The Social Determinants of Mental Health

The conditions into which we are born, live, grow, work, and age that impact our mental health are known collectively as “the social determinants of mental health,” and are responsible for many of the mental health inequities seen in society.28 Many of these determinants have been discussed previously. What has not been emphasized is how social determinants of mental health drive behavioral patterns, including restricting options that people have to make healthy decisions, limiting optimal health behavior choices that people might otherwise make, and shaping and contextualizing risk factors and protective factors associated with mental illnesses and substance use disorders. The concept of “structural competency” aims to equip providers with greater knowledge to address the social determinants of mental health.31 Because the social determinants of mental health can be considered the “fundamental causes of disease,”32 action taken to address the social determinants can lead to improved mental health outcomes and can help to reduce and eliminate mental health inequities.

Future Directions

Tackling mental health inequity requires a constellation of approaches affecting prevention, diagnosis, and treatment of mental illnesses, with a goal of reducing overall morbidity. Mounting evidence requires us to think beyond the walls of our individual patient offices (and indeed, the entire health care system) to address the social determinants of mental health, implicit bias, and discrimination. By considering social norms and public policies at their origins, providers can identify roles they may not have previously contemplated in addressing systemic discrimination and racism that disenfranchises certain populations. Especially on local, municipal, and regional levels, advocating for greater social inclusion, addressing root causes of poverty (such as poor educational quality and lack of employment opportunities), and calling attention to income inequality can separately and synergistically promote mental health and wellness at a population level.

Social Norms

The beliefs that society collectively holds, including who in society is valued and who is not, help to shape decisions on how to distribute opportunities and advantages. In the US, some population groups, including certain racial/ethnic groups, sexual minority populations, and people with serious mental illnesses, are subject to exclusion through behaviors (such as discrimination) of institutional and professional actors.

To effectively shape social norms that promote social inclusion, equity, and equal distribution of opportunities within society, psychiatrists and other mental health providers have a responsibility to speak out when social norms and collective actions reflect exclusion and engender distance between members of society. Mental health providers should serve as experts on the negative mental health consequences of discrimination, racism, sexism, and exclusionary thoughts and behaviors, and should be instrumental forces in promoting “zero tolerance policies” for these destructive behaviors in work and community settings.

Public Policies

In addition to social norms, public policies and formal laws in our communities also affect the social determinants of mental health, including housing, education, employment, health care, the criminal justice system, and others that encompass everyday life. Neighborhood, community, state, and federal laws can promote equality and inclusion, which lead to positive mental health outcomes, or alternatively, they can serve to further divide populations and groups from each other, leading to poor mental health. Public policies can also reflect and reinforce dysfunctional and stigmatizing social norms. Mental health professionals are not lawmakers or policymakers, but they can form effective partnerships with legislators and community members to advance policies that promote mental well-being and health equity.

Conclusions

The slow progress made in addressing mental health inequities over time forces us to enter perhaps uncomfortable territory to address discrimination (both interpersonal and structural), implicit biases, and social determinants of mental health. Some of these challenges lie outside the confines of medical settings. The inequity is not only in mental health outcomes but also in the social hierarchies that disenfranchise and exclude select groups. The mainstream use of “disparities” (as a descriptive phenomenon) versus “inequities” (as undesirable and preventable inequalities that demand action) in the US is an important distinction, and one highly reflective of our current political climate. Recognizing this, providers may need to expand their roles as advocates for social change, champions for inclusion, and adjuncts to policymakers to make substantial and lasting changes in our ability to reduce and ultimately eliminate mental health inequities in the future.

Authors

Ruth S. Shim, MD, MPH, is an Associate Professor, Department of Psychiatry and Behavioral Sciences. Christine E. Kho, MD, is a Resident Physician, Department of Psychiatry and Behavioral Sciences. Jann Murray-García, MD, MPH, is an Assistant Clinical Professor, Betty Irene Moore School of Nursing. All authors are affiliated with the University of California Davis School of Medicine.